Medical History Form (Page 4 of 4) in pdf

Medical History Form Page 4

OB History

Please fill in details of any deliveries:

Baby’s weight/gender/name

(e.g. 7#12 oz female, “Mary”)

Date

Vaginal or C-section?

Complications/Comments

______________________________________________________________________________________

_____________________________________________________________________________________________

________________________________________________________________________

Any miscarriages? _____

Abortions? _____

Tubal pregnancies? _____

Social History:

What is your occupation? _______________________________________

Marital Status (circle one): S M D W Separated Engaged

Name of spouse: _________________________

Tobacco use? Yes/ No

How many cigarettes per day? ______

How many alcoholic beverages do you drink per week? ___________

Use of street drugs? Yes/ No

What type(s)? _________________________

Seat belt use? (Circle one) Always/ Usually/ Seldom/ Never

How many times a week do you exercise? _______

What activities do you do for exercise? ______________________________________________________

Do you usually wear sunscreen when spending time outside? Yes/ No

Do you feel safe at home? Yes/ No

If the answer is “no,” please explain why not:

______________________________________________________________________________________

Medical History Form Page 4